MEDICARE: SANFORD CLINIC

Medicare Provider Information

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	2085B0100X	Body Imaging Physician
2	2085N0700X	Neuroradiology Physician
3	2085N0904X	Nuclear Radiology Physician
4	2085P0229X	Pediatric Radiology Physician
5	2085R0202X	Diagnostic Radiology Physician

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

NPI Number	:	1912932997
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SANFORD CLINIC

Provider Business Mailing Address
First Line	:	PO BOX 5074
Second Line	:
City	:	SIOUX FALLS
State	:	SD
Zip	:	57117-5074
Country	:	US
Telephone Number	:	605-328-6585
Fax Number	:

Provider Business Practice Location Address
First Line	:	1210 W 18TH ST
Second Line	:	STE LL03
City	:	SIOUX FALLS
State	:	SD
Zip	:	57104-4654
Country	:	US
Telephone Number	:	605-328-1410
Fax Number	:	605-328-1412

Authorized Official
Title or Position	:	VICE PRESIDENT, REVENUE CYCLE
Name	:	TONY LEE MORRISON
Credential	:
Telephone Number	:	605-328-8380

Provider Enumeration Date	:	07/11/2006
Last Update Date	:	11/27/2023

2500 E 52ND ST N , CIGNA MEDICARE SERVICES
SIOUX FALLS, SD
57104-7106

Practice Phone: 605-373-0100
Practice Fax: